TIME Mental Health/Psychology

This Bill Could Help Veterans With Mental Health

Military uniform jacket
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22 veterans commit suicide each day

Marine Clay Hunt received a hero’s welcome when he returned home to Texas after serving as a sniper in Afghanistan and Iraq. Struggling with a diagnosis of post-traumatic stress disorder, the Purple Heart-winner became a widely-recognized advocate for veterans. In 2011, two years after leaving the Marines, the 28-year-old became one of the 8,000 veterans who commit suicide every year.

Earlier this week, four years after Hunt’s suicide, the United States Senate unanimously passed the Clay Hunt Suicide Prevention for American Veterans Act, and President Barack Obama will likely sign it into law. Among other things, the new law would create a comprehensive outreach program to address veterans’ mental health and provide financial incentives to psychiatric doctors who work with veterans.

Read more: Why Can’t the Army Win the War on Suicide?

“While we are a little bittersweet, because it is too late for our son Clay, we are thankful knowing that this bill will save many lives,” said Clay Hunt’s mother, Susan Selke, in a statement.

The recently passed bill provides a good starting point to help an at-risk population, but it’s a small step forward in addressing a longtime problem that has only been growing in severity, experts say. Veteran suicide claims the lives of 22 veterans each day. At around 30 suicides per 100,000 veterans, the suicide rate is more than double the rate for the general population.

The reasons for the high suicide rates are not entirely clear, but researchers say that military life exposes soldiers to a series of risk factors that place them at a heightened suicide risk, even though someone in the military is usually healthier physically than someone in the general population.

“Going into the military isn’t going to increase your risk of suicide,” says Martha Bruce, professor of sociology in psychiatry at Cornell University. “It’s the experiences either during [service], or in the transition, or after.”

First and foremost, combat exposes soldiers to traumatic life and death situations, and depression and PTSD may result. Others soldiers return with brain injuries. All of these ailments have been linked to increased risk of suicide.

Read more: Killed in Action, Far From the Battlefield

Experts point out that even those who return from service mentally healthy and without injury issue face a tough life transition when they return home. Many cannot find immediate employment and struggle to adapt to the culture of civilian life more broadly. Only 72% of veterans of the last decade’s wars in Iraq and Afghanistan were employed in 2013, according to government statistics. Struggling to adjust, some turn to alcohol, which is another risk factor for suicide. One in four veterans exposed to heavy combat binge drinks at least once a week, according to the National Institute on Drug Abuse.

Shaped by the what Bruce calls the “self-reliant culture” of the military, veterans may be reluctant to seek help even when they recognize that they have a problem. “Culture plays a big role when it comes to not necessarily who gets distressed, but what people do in response to that,” says Christine Moutier, chief medical officer at the American Foundation for Suicide Prevention. “The culture in the military and, certainly with veterans, is a very stoic one traditionally.”

An Air Force anti-suicide program initiated more than a decade ago aimed to tackle the cultural issue by making service members feel comfortable reporting their conditions, Moutier says. And that’s a big part of what the recently passed Clay Hunt Act seeks to do. Peer support counselors will work with veterans in local communities to make addressing mental health issue feel more culturally acceptable.

Read more: Dangerous Cases: Crime and Treatment

“You have to go to where people are, both in physical location as well as in their mindset,” Moutier says.

Suicide researchers say the bill is a step in the right direction, but they also acknowledge that the complexity of the issue makes it difficult to know what the legislation’s long-term effect will be.

“There isn’t a panacea that’s going to reverse the trend,” says Mark Kaplan, a professor at the University of California, Los Angeles. “Suicide is one of the most complex public health problems out there.”

TIME Health Care

Veterans Affairs Chief Announces Big Restructuring Over Wait Times

Announcement comes on the eve of Veterans Day

The Department of Veterans Affairs will undergo a large organizational restructuring following the explosive revelations that hundreds of veterans were subjected to long wait times before receiving health care, Secretary Robert McDonald announced on Monday.

Disciplinary action had been taken against 5,600 employees within the last year and more firings were to come, McDonald told CNN, adding “we are acting aggressively, expeditiously, and consistent with the law.” The day before McDonald’s announcement, he acknowledged plans to hire around 28,000 medical professionals—including 2,500 devoted to mental health care—to join the VA’s hospitals and reduce the lack of timely appointments. He also said he intends to recruit young doctors with incentives like student loan forgiveness.

Since the scandal came to light, there have been more than 100 investigations of VA facilities take on by organizations from the FBI to the Department of Justice.

[CNN]

TIME politics

Veterans Affairs Needs to Get a Clue About PTSD Treatment

Veterans
Tom Williams—CQ-Roll Call,Inc. Iraq war veteran Zach Choate, 26, leads a group of veterans to a rally on the steps of Russell Building to call for a end to the redeployment of troops who have diagnosed with Post Traumatic Stress Disorder (PTSD). Choate was redeployed while still recovering from wounds inflicted by an IED.

Some medical centers may have a goldmine of PTSD data, which could help improve treatment. If only the department could get its act together.

Both the Departments of Defense and Veterans Affairs spend huge sums every year to treat post-traumatic stress disorder: $294 million and more than $3 billion, respectively, in 2012. But does the treatment help? According to a new congressionally mandated, 300-page report from the Institute of Medicine, neither the Pentagon nor the VA—the two agencies responsible for providing PTSD treatment to soldiers and veterans—have a clue.

The investigating committee found “spikes of excellence in both departments,” said its chairman, Sandro Galea of Columbia University’s Mailman School of Public Health. It also identified “tremendous variability in how care is implemented and an absence of data that tell us if programs are working or not.” Overall, the modest data that do appear in the IOM report are not particularly encouraging.

Members of the expert panel visited some of the VA’s Specialized Intensive PTSD Programs, or SIPPs, which are inpatient or residential programs of up to four months. They reviewed the results of all 39 such programs during 2012 and found that, after four months of treatment, the average patient still qualified for a diagnosis of PTSD.

This isn’t entirely surprising. The VA learned in the 1990s that their 16-week specialty inpatient programs were ineffective, and closed them down. Under political pressure in the 2000s, they started them up again.

But there might be good news—if only we could demonstrate it. After all, the majority of PTSD patients in the VA are not treated in inpatient or residential settings, but as outpatients. Presumably, these patients are better off than those referred to intensive programs.

So how do they fare? Are they better able to benefit from state of the art cognitive-behavioral therapies, such as prolonged exposure and cognitive processing? Clinicians routinely use these interventions to good effect in treating PTSD among civilians. We have every reason to expect that, in most cases, these therapies–in conjunction with psychotherapy and couples or family therapy or medication—have indeed helped veterans.

In any case, the IOM says there are no data. Well, not quite. While not reliably collected across the entire VA health system, there is some tracking information on treatment outcomes. For several years, the VA has required clinicians in every VA medical center to complete a PTSD Checklist (PCL) for each patient every 90 days. The PCL provides a total symptom severity score.

This enables clinicians to track changes in symptoms and establish the optimal frequency of therapy sessions, according to Ron Acierno, former director of the PTSD Clinical Team at the Ralph H. Johnson VA Medical Center in Charleston, S.C. Acierno and his team conducted routine PCLs, though how consistently and completely the surveys were administered at other VA medical centers is unknown.

In medical centers that do comply with the VA mandate to collect PCLs, there may well be a small goldmine of data to be excavated. With this information, we could answer immediate questions about the improvement of veterans’ symptoms and functioning. We could begin to learn what kinds of outcomes we see for younger veterans of the post-9/11 era and Vietnam veterans whose wartime experience is now several decades ago. Yes, Vietnam veterans are very much in the picture as new PTSD patients. One out of every three new patients in 2012 in the VA’s specialized PTSD programs was a Vietnam-era veteran, according to the IOM–even though they last saw military service decades ago.

We could also examine differences in response to treatment between active duty personnel and veterans. Our colleagues tell us, impressionistically, that men and women still in the service are, in general, more motivated than the patients they have treated in the VA. That’s because the culture of the military mental health system aims to help soldiers resume participation, while the VA’s current disability policies often reinforce illness roles and inadvertently pose disincentives to work and recovery because compensation is contingent upon the severity of PTSD.

In establishing PTSD Awareness Day, the Senate resolved to “help ensure that those suffering from the invisible wounds of war receive proper treatment.”

In some, though not all VAs, they do. Now the mission is to ensure quality care is widespread, and to learn whether treatment is helping, who benefits most (and least) and why. Veterans with PTSD deserve the best care possible; accountability is critical to seeing that they get it.

C. Bartley Frueh is chair of the social sciences division at the University of Hawai‘i at Hilo. Sally Satel is a resident scholar at the American Enterprise Institute. Both are former VA clinicians.

TIME Veterans

2 Veterans Affairs Officials Resign in Scandal’s Wake

Following Eric Shinseki's resignation

The Department of Veterans Affairs said Wednesday that two senior officials are stepping down next week as the agency looks to rebound from a scandal over concealing long wait times for veterans to get care.

The VA said the resignation of Will A. Gunn, the current General Counsel, and the replacement of Dr. Robert Jesse, the acting Under Secretary for Health, are “aimed at accelerating Veterans’ access to quality health care and rebuilding the trust of America’s Veterans.”

Jesse served as principal deputy under secretary for health beginning in 2010. In May, he assumed the new position amid reports veterans weren’t receiving adequate care. On July 2, Dr. Carolyn Clancy, who has been at the VA since 2013, will replace him.

“Dr. Carolyn Clancy is a leader and a real innovator when it comes to Veterans’ health care quality and safety,” Acting VA Secretary Sloan Gibson in a statement. “As we conduct our search for an Under Secretary for Health, there’s no one better to take on the issues we face. Dr. Clancy will be charged with the Department’s top priority – getting Veterans off of wait lists and in to see their doctors.”

Gunn’s resignation goes into effect July 3 when he will be replaced by the current principal deputy general counsel Tammy Kennedy. Gibson also announced that Dr. Jonathan Perlin, who served as the undersecretary for health under President George W. Bush, would be returning as a senior advisor to the Acting Secretary.

“We’re pleased to welcome this exceptional leader back to VA,” Gibson added. “I look forward to the contributions of Dr. Perlin who is recognized for his national healthcare leadership roles, as part of the VA team as we continue our work towards accelerating access to care and rebuilding trust with Veterans.”

Secretary of Veterans Affairs Eric Shinseki under fire in May.

“The only way today’s VA personnel actions can be viewed as positive developments is if the department fills the vacancies with leaders who put veterans first—not the VA bureaucracy—focus on solving problems instead of downplaying or hiding them, and understand that taxpayer funded organizations such as VA have a responsibility to provide information to Congress and the public rather than stonewalling them,” Florida Republican Rep. Jeff Miller, who chairs the House Committee on Veterans Affairs, said in a statement.

TIME

Sanders and McCain Introduce VA Reform Bill

Sens. Bernie Sanders and John McCain introduced a far-reaching Veterans Affairs reform bill Monday

Lawmakers are beating the drums of reform to the Veterans Affairs Department, on the heels of another scathing report released by the agency Monday.

The bipartisan bill crafted by Senators Bernie Sanders (I-Vt.) and John McCain (R-Ariz.) would fund construction of 26 new medical facilities and set up ways to make it easier for veterans to seek private care if they do not live near a VA medical facility. The bill would also improve the access to health care for victims of military sexual assault. Democratic Senate leadership said they would like to vote on the legislation this week, an aide tells TIME.

The House Republican leadership has pushed for its own legislation, which passed on a large bipartisan vote last month. That bill would give the VA secretary greater authority to fire or demote poor-performing senior officials.

The newly-introduced Senate bill comes hours after a third Veterans Affairs Department internal audit on Monday, which announced that more than 57,000 veterans have been waiting 90 days or more for their first medical appointments. This audit of the agency’s 731 medical centers found that 13% of schedulers were told by their superiors to doctor schedules to make wait times look shorter. The agency found its 14-day scheduling target unrealistic and will scrap it from employee performance contracts.

The VA wait list scandal led its Secretary, Eric Shinseki, to step down May 30.

TIME White House

Obama Marks Memorial Day With Call for Better Veteran Care

Barack Obama Veterans Memorial Day
Drew Angerer—EPA U.S. President Barack Obama and Major General Jeffrey Buchanan participate in a wreath laying ceremony at the Tomb of the Unknown Soldier at Arlington National Cemetery in Arlington, Va. on May 26, 2014.

Obama, whose administration is currently investigating allegations that Veterans Affairs facilities delayed care for needy veterans, said better support was needed for those who had fought for their country

President Barack Obama paid tribute to America’s fallen members of the armed forces at Arlington National Cemetery in Virginia on Monday to mark the Memorial Day holiday.

Obama, who returned hours earlier from a surprise visit to troops in Afghanistan, pledged again to end the war there by the end of the year and called for better support for America’s veterans, a nod to the recent troubles that have plagued the Department of Veterans Affairs. Veterans Affairs Secretary Eric Shinseki, who has faced calls to resign since it emerged that VA medical facilities had reportedly falsified records to cover up long waits for care, was in attendance.

“We must do more to keep faith with our veterans and their families,” the President said. Those who had fought for their country, he added, must “get the care and benefits they’ve earned and deserve.”

Obama stopped short of directly addressing the issue, but in an interview airing Monday afternoon with CNN, Defense Secretary Chuck Hagel said the idea of veterans on secret waiting lists being denied care “makes me sick to my stomach.”

“Because it is a clear responsibility we have as a country, as a people, to take care of these men and women and their families who sacrificed so much,” said Hagel, who still backs Shinseki. “Let’s see what happened, why it happened, how it happened. Then we’ve got to fix it.”

At Arlington National Cemetery on Monday, Obama also repeated his statement made in Afghanistan on Sunday that the U.S. was at a “pivotal moment” in Afghanistan, reiterating his pledge to pull out most troops by the end of the year.

“By the end of this year, our war in Afghanistan will finally come to an end,” he said.

Obama spoke at Arlington on its 150th anniversary, and harked back to its creation amid the Civil War.

“We declared upon this hill a final resting place for those willing to lay down their lives for the country they loved,” he said.

TIME U.S.

What the VA Did for My Sick Husband

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RodrigoBlanco—Getty Images/Vetta

Amid scrutiny and furor over misconduct at the government agency, a widow gives thanks to the employees who cared for her husband in his last years.

Two weeks ago my husband of 51 years, Joe, died in his room at the William E. Christoffersen Salt Lake Veterans Home at age 87. He had served in the Navy from 1941 to 1946 and was a proud veteran.

Like others, I am deeply concerned by reports of delayed treatment for our veterans. Indeed, when I was receiving cancer treatments in 2011 and could no longer care for Joe at home, we had to wait nearly a month before a room became available in a VA facility.

But this is not a story of disappointment. It is instead one of deep gratitude for the extraordinary professional and personal care Joe received over the next three years. Of course we must not excuse those who betray their responsibilities to our veterans and our country, but we must also remember and celebrate the legion of VA employees who provide outstanding care to our veterans, day in and day out.

As Joe’s physical strength waned and vascular dementia sapped his memory, VA doctors, nurses and aides were alert to his medical needs. Time and again they took him to the VA hospital for tests, diagnosis and treatment.

More unexpected were the countless ways in which their thoughtfulness helped Joe and our entire family. Every veteran was treated with the greatest respect, even when he or she was being difficult. For example, at first Joe didn’t understand why he couldn’t come home with me and became angry whenever I left him. The staff always took him aside to provide comfort and tell him I would be back soon.

These small personal kindnesses made such a difference.

To the extent possible, Joe and other patients were encouraged to continue a normal life. Many activities and facilities were available at the nursing home, but patients were not confined there. There were outings of all sorts, such as professional sporting events, fishing, horse riding, shopping at a local store and short road trips to see the fall leaves—even after Joe was confined to a wheelchair.

Our family was allowed to visit any time of day or night, and staff would place a call for Joe whenever he wanted to talk to us. When he could no longer come home for the day, special dinners were scheduled at holidays so we could celebrate together. It was the little things that mattered the most, and they were the most unexpected.

What turned out to be Joe’s last treat took place the afternoon before his death. By then he was in hospice care, but did not realize that his status had changed. A nurse noticed that he seemed down and asked what would make him happy. He said he wanted a Coca-Cola and a Snickers bar. She pushed his wheelchair so they could fetch them, then brought him back with her to the nurses’ station, where they visited while he indulged in this special snack.

It is difficult to leave a loved one’s side once you know that the final stages of life are here. But we knew that no matter how suddenly Joe’s final decline might be, there was no danger that he would die alone. The staff made sure that someone would always be with any patient who was approaching death so that this would never happen, and that was reassuring for us. As it turned out, the doctor was able to gather most of his family in time to be with Joe as he slipped away. The last three of us, our daughter and son and myself, whose planes from Illinois, Arkansas and Texas did not get us to the nursing home until many hours after his death. The staff had kept Joe in his room to await us. The chaplain, who had come to work for a normal day, stayed until midnight so that she could comfort us after we said our goodbyes. Only then did the mortician take Joe’s body.

A final tradition, so touching that it brings tears to my eyes as I write, is that whenever a veteran dies, his caregivers line the halls to offer their salute and play “Taps” as his flag-draped body departs.

In our case, there was a postscript. Joe had greatly admired the black Converse sneakers of two of the aides. Many times he sought to purchase them from one or the other, once offering a dollar he’d won at Bingo as payment. Although they always declined, the aides decided to surprise Joe by purchasing a pair for him out of their own funds. But the parcel arrived a few hours too late. When I urged them to return the $60 shoes for a refund, they declined, saying they were meant for Joe. Although most mourners at his funeral didn’t realize it, Joe wore his new black sneakers to the grave.

Sandra Collard has five children, fourteen grandchildren and three great grandchildren. Her husband Joe served honorably in the U.S. Navy during World War II.

TIME Veterans

VA Chief Eric Shinseki (Still) Must Go

Eric Shinseki
Cliff Owen—AP Veterans Affairs Secretary Eric Shinseki pauses while testifying before the Senate Veterans Affairs Committee hearing to examine the state of Veterans Affairs health care on Capitol Hill in Washington, May 15, 2014.

The VA is broken. It’s past time to fix this shameful bureaucratic tragedy

Back at the turn of the 21st century, when he left Washington to become president of the New School university in New York City, former Senator Bob Kerrey learned a little something about the ethos of Veterans Affairs. Kerrey, a Medal of Honor recipient who lost part of a leg in Vietnam, needed to get his home address changed. He had called his bank and settled the matter in 10 minutes. He called the VA and spoke to a hostile and not very helpful receptionist. He spoke to the receptionist’s supervisor, who told him, “You’re going to have to come in.” So Kerrey went to the VA office in New York. The receptionist again wasn’t very helpful. Kerrey pointed out that he was only talking about an address change. The receptionist said, “Talk to one of them,” pointing to customer “service” employees sitting at desks labeled A and B. Desk C was vacant. Kerrey went to Desk A, where he was told, “That’s handled by Desk C.” Kerrey asked when the occupant of Desk C was returning. “I don’t know,” said Desk A. Kerrey went over and sat at Desk C for a long while, and then a longer while. He spoke to the supervisor, who had no idea where Desk C was and told Kerrey, “Come back tomorrow.”

“You gotta be kidding,” Kerrey said, or perhaps yelled. It took 12 days to get his address changed.

I’ve heard far more serious VA horror stories ad nauseam in recent years. I know of at least one young Marine who committed suicide while waiting—months—for his medical records to be transferred from Los Angeles to Houston. I’ve also heard stories of heroic treatment performed by devoted VA doctors, nurses and counselors, but those often occurred after their patients endured a Kafka-esque struggle with the VA’s bureaucratic gate-keepers. You might expect that the system, which is staffed largely by older veterans, would have adapted with alacrity to the crisis posed by the wave of wounded Iraq and Afghanistan veterans over the past decade. But the VA’s response has been stagnation, and worse. It is now clear that there was a conscious, and perhaps criminal, effort to camouflage the time veterans had to wait for service in Phoenix and at other VA facilities. It is alleged that 40 veterans died waiting for service in Phoenix; whether or not that proves accurate, we’re facing a moral catastrophe.

The question is, How do we change this situation? The simple answer is leadership, which is why some have called (as I did last year) for VA Secretary Eric Shinseki to resign. By all accounts, Shinseki is a fine man who has spent nearly six years lost in the system. An effective leader would have gone to Phoenix as soon as the scandal broke, expressed his outrage, held a town meeting for local VA outpatients and their families—dealt with their fury face-to-face—and let it be known that he was taking charge and heads were going to roll. Instead, Shinseki intoned the words “mad as hell” at a congressional hearing. And White House chief of staff Denis McDonough said the President was “madder than hell” about the situation. Does anyone actually find this convincing?

The President cares deeply about the troops; he visits the wounded in the hospitals all the time; it’s just not his style to make a public deal of it. But he has been sadly ineffective on the veterans–health issue. The benefits system is still rigged against recent veterans, who go to the end of the line with their claims. Five years ago, Obama promised a unified electronic records system so that a soldier’s medical history would follow him or her seamlessly from active duty to the VA, but it still hasn’t been implemented because of trench warfare between the Pentagon and the VA. More than a billion dollars has been spent on the project. A senior Administration official told me a year ago that a solution was weeks away; now the Administration is promising a new system by 2016. The President could have solved this problem yesterday, by cracking heads—and selecting either the existing VA or Pentagon electronic records system. (Believe it or not, the VA system is pretty effective but not up-to-date.)

The problem of bureaucratic stagnation at the VA (and throughout the rest of the government) could be addressed as well. Think about the lazy clerks Bob Kerrey faced. Why were they so callous? Because under the existing, antiquated civil-service system, they face practically zero threat of being fired. The President could ask for a temporary waiver of civil-service rules to clean up the mess at the VA, but that seems politically impossible. Government accountability is a popular mantra—but you can’t have accountability unless everyone, including Desk C, is held to account.

TIME White House

Adviser: Obama ‘Madder Than Hell’ About VA Scandal

President Obama is urging Veterans Affairs Secretary Eric Shinseki to fix issues in the VA's hospital system after his testimony last week before the Senate Veterans Affairs Committee about reports that at least 40 veterans died while waiting for care at a Phoenix hospital

President Barack Obama is “madder than hell” about reports of long wait times that led to preventable deaths at veterans’ hospitals, according to a top adviser.

White House Chief of Staff Denis McDonough said on Sunday on CBS’s Face the Nation that Obama is urging Veterans Affairs Secretary Eric Shinseki to “continue to fix these things until they’re functioning the way that our veterans believe they should.”

Shinseki himself used similar language last week when he testified in front of the Senate Veterans Affairs Committee about reports that at least 40 veterans died while waiting for care at a Phoenix VA hospital.

“Any allegation about any adverse incident like this makes me mad as hell. I could use stronger language here, Mr. Chairman, but in deference to the committee, I won’t,” Shinseki said on Thursday.

Dr. Robert Petzel, the VA’s top health official, resigned on Friday. House Republicans have also scheduled for Wednesday a vote on legislation that would expand Shinseki’s firing power.

TIME Veterans

Top Veterans Affairs Health Care Official Resigns

Veterans Affairs Secretary Eric Shinseki Testifies Before Senate Robert Petzal
Andrew Harrer—Bloomberg/Getty Images Eric Shinseki, U.S. secretary of Veterans Affairs (VA), left, and Robert Petzel, U.S. VA undersecretary for health, swear in to a Senate Veterans' Affairs Committee hearing in Washington, May 15, 2014.

Undersecretary for Health Dr. Robert Petzel has stepped down a day after being grilled in Congress amid uproar over alleged malfeasance and cover-ups at the Department of Veterans Affairs. Petzel said in September that he planned to retire this year

Updated 7:18 p.m. ET

Secretary for Veterans Affairs Eric Shinseki announced Friday he accepted the resignation of the official in charge of the VA’s healthcare services.

Undersecretary for Health Dr. Robert Petzel offered his resignation a day after sitting aside Shinseki while both men were grilled on Capitol Hill. Shinseki and Petzel faced questions Thursday about long-standing inefficiencies in the VA’s healthcare system, as well as allegations that VA officials covered up evidence of delays at a Phoenix, Arizona, clinic that may have led to the deaths of 40 veterans.

“As we know from the Veteran community, most Veterans are satisfied with the quality of their VA health care, but we must do more to improve timely access to that care,” Shinseki said in a Friday statement. “I thank Dr. Petzel for his four decades of service to Veterans.”

Petzel said in September that he planned to retire this year, according to the Associated Press.

“As the President has said, America has a sacred trust with the men and women who have served our country in uniform, and he is committed to doing all we can to ensure our veterans have access to timely, quality health care,” the White House said in a statement. “He has asked Secretary Shinseki to conduct a review of Veterans Health Administration practices and procedures at its facilities nationwide to ensure better access to care, and that review is ongoing.”

This post was updated with a statement from the White House.

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